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9N Safety/Falls Pilot – SSS guide . Falls/Safety Documentation Changes – Why change?. Changing focus from repetitive screening for Falls Risk to a model that supports Falls Prevention

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9N Safety/Falls Pilot – SSS guide

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9N Safety/Falls Pilot – SSS guide


Falls/Safety Documentation Changes – Why change?

  • Changing focus from repetitive screening for Falls Risk to a model that supports Falls Prevention

  • Historically for each new issue addressed, we’ve added a new section or Tab to HED – not sustainable and adds complexity to documentation

  • Framework developed to identify and address all safety risks efficiently


Pilot: 9N September 18th

  • Pilot focuses on:

    • Falls Risk portion of new Safety Build

    • Other New features that will be addressed:

    • Role/Communication documentation

    • Changes in documentation of Patient/Family education & engagement

    • Changes in Restraint, CIWA, and some other safety-related documentation


TRAINING

  • RNs complete hands-on check off on documentation and workflow associated with new Falls/Safety HED build

    Practice Scenario:

    • Determine the Morse Falls Risk Score

  • Identify safety risk factors and safety problems ; Start Safety or Restraints Priority Problem, if warranted

  • Document, Care Interventions, Patient/Family Teaching, and any Notifications & Care Coordination

  • Document shift goals/outcomes for Safety Priority Problems & response to safety interventions


  • Safety Risk Assessment Tab

    Safety Risk Assessment

    Safety Plan

    Response to Interventions

    1. Assess

    2. Care

    3. Educate

    4. Notify


    Morse Falls Risk Screen


    Education Tab

    • Role Communication Section(caregiver contact info)- nurses to document caregivers contact info once and if any phone number changes

    • Education Categories – categorized in similar fashion to Priority Problems


    9N Pilot: What’s Changing

    • Safety assessment on every patient every shift. Also

      • 9N: Morse Falls screen on admission & with change in status/condition (e.g. Transfer to different level of care, change in mental status, etc.)

      • 6A/B: PEWS screen documented q4h (will be moved from Falls/Safety Tab at conclusion of pilot before VCH-wide rollout)

    • Safety Problems(Injury Risk, Violence Risk, Substance Abuse, and others ) will be identified.

      • If they are a priority, also initiate this as a Priority Problem

    • Safety Interventions will be documented – things you:

      • Assess/Monitor/Evaluate/Observe

      • Care/Perform/Provide/Assist

      • Teach/Educate/Instruct/Supervise

      • Manage/Refer/Contact/Notify


    9N Pilot: What’s Changing

    New Education Tab:

    • Caregivers’ contact information (“Care Contacts”) – will be documented in new Role/Communication section

    • Patient/Family Education & Engagement

    • Some other Safety documentation (eg. Restraints) streamlined.


    What’s NOT Changing

    • Plan of Care documentation

      • Priority Problems – continue to create and evaluate goals

      • Pathway, Nursing Summary, and Plan Priorities documentation in HED

      • Continue to assign e-docs pathway

      • Education Record tab still visible for pilot until further discussion as to whether to blend the new Education tab with current one

    • Admission History documentation of substance screening and caregiver contact information will still be recorded until further evaluation with pilot


    What to Do & When

    • Admission

    • Morse Falls Risk screen

    • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted

    • Beginning of Shift

    • Safety assessment; Identify problems & Plan Interventions

    • Document expected Short Term Goals for Safety Priority Problems

    • Start/End Safety Priority Problems if warranted

    • Document Short Term Goal Status or outcome for Priority Problems

    • Document Response to all Safety Interventions

    • End of Shift

    • Morse Falls Risk screen

    • Repeat other Safety Assessment & Revise Planned Interventions as appropriate

    • Condition/ Status Change


    • Morse Falls Risk screen

    • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted

    Admission

    • Click on HED Train tab and select the Safety Falls/ Risk tab

    • Locate and complete the Morse Falls Risk Section – bottom of screen

    • Complete Safety Risk Assessment


    • Morse Falls Risk screen

    • Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted

    Admission

    • How would you assess the patient’s:

      • Ambulation aid

      • Gait

        Hover over boxes with HED Upgrade on many fields


    • End of Shift

    • Start/End Safety Priority Problems if warranted

    • Document Short Term Goal Status or outcome for Priority Problems

    • Document Response to all Safety Interventions

    • Continue to document:

      • Nursing Summary, Plan Priorities, and Goal Status

    • Include from Safety/Falls tab end of shift documentation on:

      • Response to Safety Interventions


    • Morse Falls Risk screen

    • Repeat other Safety Assessment & Revise Planned Interventions as appropriate

    • Condition/ Status Change

    • Re-Assessment of Morse Falls Risk Screen and Safety Assessment with:

      • Change in level of care (unit-to-unit)

      • Status Change

      • Fall or injury

      • Increased monitoring of patient’s condition due to status change


    9N Go Live – Sept 18th

    Day of go-live also

    New Safety/Fall Risk tab will replace the old Falls Risk section in assessment tabs

    New Education tab will appear- old Education Record tab will still be visible

    Restraints documentation moved from Restraints tab to Safety/Fall Risk tab

    Past data will be viewable for the Restraints tab, and Fall Risk section but will not contain charting boxes.

    CIWA tab released


    Training and Implementation Plan

    • Resources:

      • Super Users – in-staffing

      • Educator

      • Unit Resource Manual- contains issue

        log, pocket aides, staff& support

        schedule, and pocket aides

    • Implementation Support

      • SuperUsers

      • SSS/CAPS: 9a-5pm and 9pm to 5am, Sept. 18, 19, 20, 21st

      • Issues Log on unit


  • Login